Lymphangiogenesis in Crohn's disease: an immunohistochemical study using monoclonal antibody D2-40

Crohn's disease (CD) is a chronic inflammatory bowel disorder of unknown etiology. An involvement of the intestinal lymphatic system has been suggested. Recently, monoclonal antibodies have become available to distinguish lymphatic vessels from blood vessels. The aim of the study was to examine the distribution of lymphatic vessels in ileal and colic walls of patients affected by CD and compare it with healthy controls and other inflammatory bowel diseases. Twenty-eight cases of CD, 13 cases of other inflammatory bowel diseases, and 10 normal ileal and colic walls were studied. Immunohistochemical staining was performed using the monoclonal antibody D2-40. Quantification of lymphatic vessels was performed by identifying four fields with high density of lymphatics and then counting the number of lymphatic vessels at high resolution. Lymphatic diameter was also evaluated by using an ocular micrometer. Lymphatic vessels showed the highest density in CD specimens. The median number of lymphatics was significantly higher both in ileal and colic samples of CD than the other inflammatory diseases as well as normal controls. Moreover, in patients with CD, diffuse lymphangiectasia was also observed. The present data suggest that lymphangiogenesis and lymphangiectasia probably play a role in the pathogenesis of CD.

Effect of chlorhexidine digluconate on different cell types: a molecular and ultrastructural investigation

Although several studies have shown that chlorhexidine digluconate (CHX) has bactericidal activity against periodontal pathogens and exerts toxic effects on periodontal tissues, few have been directed to evaluate the mechanisms underlying its adverse effects on these tissues. Therefore, the aim of the present study was to investigate the in vitro cytotoxicity of CHX on cells that could represent common targets for its action in the surgical procedures for the treatment of periodontitis and peri-implantitis and to elucidate its mechanisms of action. Osteoblastic, endothelial and fibroblastic cell lines were exposed to various concentrations of CHX for different times and assayed for cell viability and cell death. Also analysis of mitochondrial membrane potential, intracellular Ca2+ mobilization and reactive oxygen species (ROS) generation were done in parallel, to correlate CHX-induced cell damage with alterations in key parameters of cell homeostasis. CHX affected cell viability in a dose and time-dependent manners, particularly in osteoblasts. Its toxic effect consisted in the induction of apoptotic and autophagic/necrotic cell deaths and involved disturbance of mitochondrial function, intracellular Ca2+ increase and oxidative stress. These data suggest that CHX is highly cytotoxic in vitro and invite to a more cautioned use of the antiseptic in the oral surgical procedures.

Oxaliplatin, 5-fluorouracil/leucovorin and epirubicin as first-line treatment in advanced gastric carcinoma: a phase II study

The association between oxaliplatin and 5-fluorouracil (5-FU) has been extensively reported to improve prognosis of gastric cancer patients. The present study is aimed at evaluating response rate and the toxicity profile of the association with oxaliplatin, 5-FU/lecovorin and epirubicin in gastric cancer patients with locally advanced or metastatic disease. Thirty-six patients have been enrolled and 35 evaluated. The treatment schedule was oxaliplatin (100 mg m(-2)), 5-FU (400 mg m(-2)), leucovorin (40 mg m(-2)) and epirubicin (60 mg m(-2)) intravenously. administered every 3 weeks for 6 months, for a total of 185 therapy cycles . Response rate and toxicity were assessed according to the international WHO criteria. Every patient received a mean of 5.3 therapy cycles in a day-hospital setting. Sixteen of 35 patients (46%) showed an objective response, two complete response and 14 partial response. Median time to progression was 33 weeks with an overall median survival of 49 weeks. During the study, anaemia grade 3 and neutropenia grade 3 were observed in 9 and 11% of patients respectively. A grade 3 periferic sensorial neuropathy was observed in 6% of patients. No life threatening or cardiac toxicity was recorded. The regimen used showed anticancer activity against gastric carcinoma, a tolerable toxicity profile and excellent patient compliance.

Osteonecrosis of the jaws in periodontal patients with a history of bisphosphonates treatment

BACKGROUND/AIM

Osteonecrosis of the jaws is being increasingly reported in patients with bone metastasis from a variety of solid tumours and disseminated multiple myeloma receiving intra-venous bisphosphonates. The signs and symptoms that may occur before the appearance of clinical evident osteonecrosis include changes in the health of periodontal tissues, non-healing mucosal ulcers, loose teeth and unexplained soft-tissue infection. A series of nine periodontally involving patients showing osteonecrosis of the jaws that appeared following the intra-venous use of bisphosphonates is reported.

MATERIAL AND METHODS

Nine consecutive patients with osteonecrosis of the jaws were prospectically studied. Patients' past medical histories and the drugs that they had received for their malignant disease were systematically documented. Clinical, histopathological and radiographic features and proposal for treatment modalities of osteonecrosis are also reported.

RESULTS

Of the nine patients (six women and three men) observed, all had osteonecrosis in the mandible; two had maxillary involvement as well. All nine patients had a history of extraction of periodontally hopeless teeth preceding the onset of osteonecrosis. In two patients, the lesions also appeared in edentulous areas spontaneously. All the patients had received intra-venous bisphosphonates as treatment for their disseminated haematological neoplasms or metastatic bone disease. The duration of bisphosphonate therapy at presentation ranged from 10 to 70 months (median: 33 months).

CONCLUSIONS

Jaw osteonecrosis appears to be associated with the intra-venous use of bisphosphonates. Dental professionals should be aware of this potentially serious complication in periodontal patients receiving long-term treatment with bisphosphonates.

Counting of platelet derived growth factor and transforming growth factor-beta in platelet-rich-plasma used in jaw bone regeneration

AIM

Growth factors (GFs) as platelet derived growth factor (PDGF) and transforming growth factor (TGF-beta), found in platelet beta-granules also present in platelet-rich-plasma (PRP), accelerate bone revascularization and regeneration and for this reason they have been employed successfully in dental and maxillofacial surgery. Platelet concentrate is commonly used for this purpose as long as platelet release reaction and the consequent GFs loss are avoided. To reduce this phenomenon we set up an easy and fast procedure for preparing a satisfying clotted PRP by adding CaCl2 only (no exogenous thrombin).

METHODS

ELISA essay has been used to measure PDGF and TGF-beta in plasma, platelets and serum and platelet GMP-140, with the cytofluorometric technique in order to quantify the degranulation entity.

RESULTS

In the 13 examined patients receiving clotted PRP to enhance bone regeneration in post-extractive alveolar sockets, PRP showed no sign of platelet activation (degranulation) and short recalcification times (8-12 min). The autologous clotted PRPs specimen have been evaluated in laboratory in terms of GFs percent: 76% of initial GFs content could be recovered in clotted PRP. This result confirms the absence of platelet degranulation in our procedure.

CONCLUSIONS

Significant clinical results in alveolar bone regeneration are reached only with a high percentage of GFs inserted in bone matrix, avoiding early platelet degranulation.

[Laparoscopic approach to the "acute" and "chronic" bowel obstruction]

AIM OF THE STUDY

To retrospectively evaluate a series of patients with acute and chronic small bowel obstruction and discuss the indications of laparoscopic vs laparotomic approach and the outcome of both these techniques.

PATIENTS AND METHOD

85 patients with acute and chronic small bowel obstruction who underwent to either emergency or elective surgery since January 1999 up to October 2001 were enrolled. Subjects were divided into three groups: 39 treated with emergency laparotomy (group I), 13 with emergency laparoscopy (group II) and 33 with elective laparoscopy for chronic/subacute obstructions (group III).

RESULTS

1) the most frequent indication of the laparotomic approach was either multiple or major previous surgery as well as neoplastic diseases; 2) patients of the second group had frequently previous either minor or laparoscopic surgery; 3) the incidence of previous emergency surgery were maximum among the III group; 4) both post-operative ileus and mean hospital stay lasted less in the II than in the I group. The mean operative time and the morbidity was equal in the two groups; 5) we observed more intra-operative complications, a higher conversion rate and a longer both post-operative ileus and mean hospital stay in the II than in the III group.

CONCLUSIONS

Our data support the role of laparoscopy in patients with chronic/subacute small bowel obstruction. Patients with acute obstruction may undergo laparoscopy after a careful selection, excluding subjects with previous either multiple or major surgery as well as neoplastic diseases. Such results need future confirmations from prospective randomized studies.

The influence of new technologies on laparoscopic adrenalectomy: our personal experience with 91 patients

BACKGROUND

Laparoscopic adrenalectomy has proved to be the technique of choice for managing benign pathologies of the adrenals and isolated adrenal metastases, especially those arising from lung tumor, but the procedure should not be performed for primitive adrenal carcinoma. The Authors wanted to test the advantages of the Harmonic Scalpel in laparoscopic adrenalectomy.

METHODS

From April 1995 to April 2001, the authors investigated their series of laparoscopic adrenalectomies performed at the Careggi General Hospital, Division of General and Vascular Surgery, Florence, Italy. This study enrolled 91 patients with various adrenal pathologies. The transperitoneal approach was used, with the patient in a lateral position, as suggested by Gagner. Special care was taken to improve the surgical approach to the adrenals by the use of new technological devices such as the Harmonic Scalpel. The operative time required by the surgical procedure was computed by dividing the study into three periods: 1995-1997, 1998-1999, 2000-2001. The first period was necessary to complete the learning curve. In the second period, a steady state in surgical time was reached. During the third period, the Harmonic Scalpel was introduced. The differences between the three periods were tested using a nonparametric analysis (Mann-Whitney U test or Kruskal-Wallis test) as appropriate. A two-tailed p value of 0.05 or less was considered statistically significant. The authors investigated the cost of the operation performed in each of the two groups using, respectively, the conventional laparoscopic device (1998-1999) and the Harmonic Scalpel (2000-2001). The following expenses were considered: Harmonic Scalpel impulse generator and disposable shears, operating room cost per hour, and endoclip applier.

RESULTS

The 91 laparoscopic adrenalectomies were performed with these indications: 31 incidentalomas (26 adenomas and 5 cysts), 25 cases of Conn's disease, 18 cases of Cushing's disease, 9 pheochromocytomas, 2 myelolipomas, 5 metastases (from lung, kidney, and breast) and 1 primitive carcinoma diagnosed preoperatively. Considering the whole series (1995-2001), there was a significant trend of reduction in operative time (p = 0.0001). Moreover looking at the first period (1995-1997), in which the learning curve was completed, the mean surgical time was 148 min, as compared with 125 mm. For the second period (1998-1999) (p = 0.0002). This represents a significant reduction in operative time. The authors noted a further reduction in the operative time when surgery was performed with the Harmonic Scalpel (2000-2001) (92 min; p = 0.001). The reduction in operative time attributable to the Harmonic Scalpel was confirmed also by a multivariate analysis of covariance general linear models procedure (GLM), which accounts for several confounders: age, gender, site and size of tumors, and histology (p = 0.0001). The rate was 3.3% for morbidity, 1.1% for mortality, and 2.2% for conversion. There was no difference in complications between patients treated with conventional devices and those treated with the Harmonic Scalpel.

CONCLUSIONS

The laparoscopic approach has proved to be an extremely reliable procedure for benign pathologies and isolated metastases. There may yet be doubts about its use for the treatment of adrenal carcinomas preoperatively diagnosed. When surgery is performed using Harmonic Scalpel, operative time is significantly reduced and surgery is easier and less expensive. Infact use of the Harmonic Scalpel allowed the cost per operation to be reduced $70. Moreover, if surgery is performed using the nondisposable clip applier, the expenses are reduced $105.

Management of upper respiratory tract infections in primary care in Italy: a national survey

This prospective study, carried out in Italy during the winter of 1998 by the means of questionnaires, was designed to investigate the diagnostic and therapeutic approach of the Italian general practitioners (GPs) to the management of acute upper respiratory tract infections (URTIs) in adult outpatients. A total of 354 GPs were questioned about ten adult patients each who had visited the surgery with an URTI requiring an antibiotic prescription. Our data showed there was a tendency to prescribe antibiotics only on the basis of clinical diagnosis, microbiological investigations being required very rarely. Orally administered antibiotics were preferred and compliance with the number of daily doses strongly influenced the antibiotic prescription. In patients affected by more severe infections, injectable antibiotics were frequently prescribed.

[Odontogenic chronic maxillary sinusitis: regenerative possibilities of oro-antral defect]

Odontogenic maxillary sinusitis often develops into a chronic picture of unilateral inflammation, progressively interesting the whole antrum mucosa. The only decisive therapy of this pathology is a surgical one that, by completely removing pathologic tissues, starts sinus restoration by a healthy respiratory mucous membrane. This tissue grows from the nasal cavity after the radical surgery (according to Caldwell-Luc), presupposing an antrum drainage through that same cavity. Nevertheless, if the inflamed area is just limited in the central and posterior recesses, and the hiatus semilunaris of the medial wall remains open, it is possible to avoid a surgical access to the nasal cavity. In this way, an alternative surgery is proposed for chronic sinusitis which, using principles of Guided Bone Regeneration, permits to completely remove pathologic tissues and to start bone reformation in the damaged alveolar.

Short course therapy with cefitbuten versus azithromycin in pediatric streptococcal pharyngitis

OBJECTIVE

To compare the safety and efficacy of a short course (5 days) of ceftibuten vs. azithromycin for 3 days for treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis in children.

METHODS

A multicenter, open label, prospective, randomized trial in which patients > or =3 to < or =16 years of age with proven GABHS pharyngitis were randomized to receive either once daily ceftibuten for 5 days or azithromycin for 3 days. Patients were evaluated for clinical outcomes and/or for adverse events at days 6 to 8, 13 to 15 and 33 to 35 posttherapy. Microbiologic assessments (pharyngeal cultures) were conducted at baseline and at each follow-up visit.

RESULTS

A total of 132 patients in the ceftibuten arm and 116 in the azithromycin arm were enrolled in the safety analysis, whereas 126 and 101, respectively, were enrolled for ceftibuten and azithromycin efficacy evaluation. Clinical success (cure or marked amelioration) at days 6 to 8 was recorded in 98 and 94% in the 2 groups, respectively. In the bacteriologic efficacy analysis at 6 to 8 days, the GABHS strain was eradicated in 76% of the patients treated with ceftibuten and in 76% of those receiving azithromycin. At 33 to 35 days, 84% of the patients in the ceftibuten arm and 71% in the azithromycin arm were GABHS-negative, and bacteriologic relapse was observed in 4 and 7% of the ceftibuten and azithromycin cases, respectively. Both treatments were well-tolerated by all patients.

CONCLUSIONS

Ceftibuten and azithromycin allow simple treatment schedules (i.e. once daily administration, short duration of treatment). The somewhat higher eradication rate recorded after ceftibuten administration is consistent with the overall superior bactericidal activity of beta-lactams compared with macrolides vs. GABHS in vitro.

[New developments in Crohn's disease: unravelling the mystery of its etiopathogenesis and its reinstatement as a surgically treatable condition. Part 3: The rational principles of surgical therapy]

The diagnosis of Crohn's disease makes surgery mandatory in any form of the disease, because it is ingravescent, spreads in the bowel, and is unresponsive to any type of pharmacological treatment; it invariably involves major consequences and often leads to serious complications such as perforation and cancer in the long term. The operation has to be performed promptly, because the commonest complications, such as obstruction and perforation, may occur at any stage of the disease, including the initial phase. Moreover, it is advisable to prevent the spread of the disease to the colon and jejunum, which occurs in increasing percentages of patients and is related to duration of the disease. As a rule, surgery has to take the form of a resection of the diseased bowel, which includes not only the lesions already in progress, but also those which may be expected to develop. Therefore, since the disease is segmentary, the resection, too, has to be segmentary, even when part of the diseased segment is apparently sound. Inadequate resection is often followed by dehiscence of the anastomosis and sooner or later by an inevitable recurrence. Three types of resection are performed for Crohn's disease depending on whether it manifests as ileitis, ileitis plus right colitis, or ileitis plus right and left colitis. Ileitis requires an ileocolic resection. Because the resection has to be segmentary and the proximal limit of the segment, i.e. of the lesions, cannot be determined at external examination of the intestine, the surgeon has to perform an approximate, temporary resection and examine the resected specimen, open along its entire length, before constructing the anastomosis. The borderline between the diseased and intact ileum, where convinient valves, appear with their thin, delicate outline, can be identified exactly in the mucosal surface. The resection has a "safety margin" of 10 cm. Section of the ascending colon can be performed wherever the surgeon prefers. The ileitis plus right colitis forms require resection of the ileum according to the procedure described and of the right colon, even when the lesions are confined to the caecum. Section and anastomosis must be performed in the initial tract of the transverse colon. The ileitis plus right and left colitis forms call for total colectomy in addition to resection of the ileum, even when the lesions are confined to the transverse colon. The operation is completed with an ileorectal anastomosis constructed on the lower portion of the intraperitoneal rectum (drained by the hypogastric collectors).

[New development in Crohn's disease: ++unravelling the mystery and its reinstatement as a surgically treatable condition. Part 2. Potential etiopathogenesis of "terminal ileitis" and extension of the disease to mesenteric small intestine and the colon]

INTRODUCTION

The aetiopathogenesis of terminal ileitis is still unknown, as is the cause of its spread to the small and large bowel. The aim of this study was to shed light on these unknown aspects of Crohn's disease.

CONCLUSIONS

The lack of patency of the ileal branch of the ileocolic lymphatic collector which causes terminal ileitis, usually in the earlier part of life, is likely to occur in the foetus around the 10th week of pregnancy as a result of a minor abnormality of the physiological regression of the vitelline duct. Excessive atrophy of the lymphatic network seems to occur, also affecting the rudimentary lymphatic vessels in the midgut destined to become the terminal ileum. The terminal ileitis spreads to the large bowel in an increasing percentage of cases and is directly related to duration of the disease, causing first ileitis plus right colitis, and then ileitis plus total colitis (which, however, does not include the rectum). It may also include the jejunum, causing skip lesions. This spread of lesions is not due to any genetic predisposition (that is to say, it is not predetermined in empirical terms), but rather to the extent of the lymphatic obstruction caused by the spread of immunocomplexes via the lymphatic network. This is shown by the fact that secondary lesions of the jejunum and large bowel are also typical of lymphoedema and that their spread is segmentary. In the light of these pathogenetic mechanisms, it is reasonable to assume that the spread of the process from the ileum to the colon might be prevented by prompt surgery during the initial phase of the ileitis. If these views are correct, the traditional subdivision of Crohn's disease forms into ileitis, ileocolitis and solitary colitis should be replaced by a very simple scheme showing the spread of the primary ileitis very often to ileocolitis, first confined to the right colon and then total. We cannot include either solitary colitis (not clearly defined in the literature) or anorectal Crohn's disease (whose forms have yet to be fully acknowledged) in this scheme.

[New developments in Crohn's disease: solution of doctrinal mysteries and reinstatement as a surgically treatable disease. 1. The process is not a form of enteritis but lymphedema contaminated by intestinal contents]

INTRODUCTION

It is unanimously acknowledged that the aetiopathogenesis of Crohn's disease (CD) is still a mystery despite the fact that almost 70 years have elapsed since it nosological identification. Another mystery and major problem of CD of the bowel is its histopathology, which has yet to be clarified; consequently, we do not know what kind of disease it is, that is to say, which process, among the ones known to us, it actually corresponds to.

MATERIAL AND METHODS

The present paper presents the results of a new histopathological interpretation of the disease on the basis of 100 surgical cases of Crohn's ileitis and ileocolitis.

RESULTS AND CONCLUSIONS

The disease is not a form of enteritis, but a lymphoedema of the intestinal wall, caused by a congenital lack of patency of the mesenteric lymphatic collectors, giving rise to stasis of lymph in the lymphatic network of the corresponding bowel segment and consequently to hypertension which dilates the lymph vessels in the intestinal wall. The lymph, which cannot be reabsorbed by the veins, because the venous wall denies entry to protein macromolecules, accumulates in the interstitial space with the result that the intestinal wall thickens considerably. Since the process takes place in the intestine perfused by a continuous flow of septic matter, the process is complicated by the development of lymphocytic lymphangitis, which occurs throughout almost the entire lymphatic network, obstructing the dilated lumen, limiting the dispersion of lymph and preventing gross spread of the intestinal contents into the dilated lymphatic vessels. The lymphocytic lymphangitis causes "transparietal phlogosis", which is rightly regarded as a characteristic of the disease, but is wrongly interpreted by those who have studied it. This transparietal phlogosis is neither excessive nor disproportionate to its task of obstructing the intestinal contents; it is transparietal because the lymphatic network where it takes places is itself transparietal. The reactive lymphocytic lymphangitis prevents the gross spread of the intestinal contents into the dilated lymphatic network, as stated above, but cannot prevent the limited uptake of dissolvable toxic bacterial substances (FMLP, PG-PS, LPS) conjugated in immuno-complexes. The immuno-complexes developing in the lymphatic network undergo lymph- and blood-borne spread, causing; obstructive lymphangitis in branches of the mesenteric lymphatic collectors which are still patent, increasing the degree of lymphatic obstruction and thus the extent of the intestinal lesions; general complications of so-called "metastatic Crohn's disease", which were once interpreted as autoimmune processes, but actually correspond to forms of vasculitis which may be localised in any of the organs or apparatuses of the body, sometimes proving extremely serious. Lymph dispersion in the intestinal lumen, causes not only diarrhoea, but often also lymphocytopenia and hypoproteinaemia, and therefore an immunodepression syndrome, which in the long term may give rise to intestinal and extraintestinal cancer.

[Long-term central venous access. Experience with 173 cases]

BACKGROUND

Utility of long term central venous accesses.

METHODS

Personal experience in 173 long term central venous accesses (a.v.c.) performed from January 1990 to December 1997 in 172 patients mostly affected by neoplastic disease is reported. The device used was totally implantable in 102 cases (59%): 82 Port (80.3%), 20 Chrono-infusors (20.7%); in 71 cases (41%) an external tunnellized catheter (c.v.c.). Percutaneous way with Seldinger procedure was performed in 168 cases (97.3%), left subclavian vein was preferred in 118 cases (68.2%).

RESULTS

The overall complications in this series were about 7.4%: early 4% (5 accidental arterial punctures, 2 pneumothoraxes), late 3.4% (1 subcutaneous pocket infection, 3 cutaneous necrosis, 1 venous catheter dislocation and 1 migration). No significative differences in terms of complications were reported between totally implantable devices and external tunnellized catheter.

CONCLUSIONS

The reasons of a low rate of complications in our series are to be found in the perfect aseptic condition of the operating room, the positioning of the a.v.c. under constant fluoroscopic control and a good management during the postoperative care of the a.v.c. The indications and the economic aspect for each kind of device used (c.v.c. or totally implantable a.v.c.) are then discussed and the conclusion drawn that for short term therapy, up to six months, (hematologic patients of this series) the external tunnellized catheter should be advisable, while for long term therapy administration (solid tumors and parenteral nutrition) totally implanted device should be recommended.

[Gastric carcinomas of the "bare area". Their anatomo-surgical definition and proposal of an en bloc total gastrectomy]

INTRODUCTION

Regarding the surgical treatment, carcinomas of the gastric proximal third and cardia are considered as an uniform problem. Particularly no difference exists between the gastric tumors of the anterior wall and those of the posterior wall. Nevertheless, cancers of the posterior wall of the proximal third are more difficult to cure and therefore less success has been achieved than with those of the anterior wall. The cause of this different behaviour must consist in an anatomical characteristic, the fact that the posterior wall of the fundus and subcardial portion is not covered by the visceral peritoneum ("bare area").

MATERIAL AND METHODS

Our study group consisted of 22 patients who presented carcinoma of the stomach risen in the area without peritoneal lining. Our treatment of this condition consisted of an operational procedure wherein we removed en bloc the stomach, left pancreas, spleen, and lymph nodes of the compartment I, II and III. In each case we considered the pathological situation, the involvement of the retroperitoneal structures and the condition of the lymph nodes in the compartment III specially, and actuarial statistics.

RESULTS

We divided the 22 patients in 4 groups based on the neoplastic involvement of the retroperitoneum. Only in 3 cases (14%) of group 1 the cancer invasion was limited to the gastric muscular layer. In all of the rest, tumor involved the retroperitoneal structures. Postoperative mortality rate was 9%. The five year survival rate was 100% in the 3 cases of group 1 only and 10.5% in all other cases.

DISCUSSION

The results show that carcinomas of the "bare area" cause a real jump in the degree of severity of the biological neoplastic process and hence of the prognostic evaluation. When the growth involves the gastric muscular layer, it indicates invasion of the retroperitoneum. Therefore, as with surgical treatment of esophageal carcinoma with the en bloc esophagectomy, we propose an en bloc total gastrectomy which should be performed in every carcinoma arising in the "bare area" because it allows more radical removal than can be obtained from traditional surgical procedures, without risking an increased mortality rate.

Clinical and pharmacological evaluation of a modified cefotaxime bid regimen versus traditional tid in pediatric lower respiratory tract infections

It is generally accepted that the treatment of community-acquired pneumonia, either in adults or in pediatric patients, is mainly empirical. Thus, the treatment selection must fulfill both the epidemiological requirements, according to the most frequently described pathogens, and the pharmacological criteria to ensure adequate and prolonged drug concentrations at the infection site, to reach clinical efficacy. Cefotaxime has proven to be effective in this indication when traditionally administered three times daily and, more recently, twice daily, as a result of a re-evaluation of its pharmacokinetic/pharmacodynamic features. To gain further evidence using this updated dosing schedule, 258 pediatric patients with lower respiratory tract infections were treated with cefotaxime 100 mg/kg/day, administered as a twice daily or three times daily regimen. In the cefotaxime 50 mg/kg twice-daily group (n = 130), a complete resolution of clinical signs and symptoms were observed in 88.5% of patients. Similarly, in the cefotaxime 33.3 mg/kg group (n = 128), 93.6% of patients had a complete resolution of clinical signs and symptoms. Both drug schedules were well tolerated. Pharmacokinetic parameters determined for the two cefotaxime dosing schedules showed comparability. The serum half-life of desacetylcefotaxime was marginally longer than for cefotaxime in both dosage groups (1.64 and 1.36 h for desacetylcefotaxime versus 1.2 and 0.85 h for cefotaxime after 50 mg/kg or 33.3 mg/kg doses, respectively). Results from this study support the use of twice-daily cefotaxime administration for the treatment of lower respiratory tract infections in pediatric patients.

Effects of ipriflavone on perialveolar bone formation

The effect of ipriflavone (IP), a synthetic isoflavonoid derivative, on in vivo bone formation was studied in rat perialveolar bone by surgically producing a hole in the mandibular bone. The holes were filled either with powdered IP or with compounds containing no osteoinductive properties such as biostite and Htr (hard tissue replacement). In control animals, the holes were left to heal spontaneously. The animals were killed 3, 28, and 40 days after surgery and a detailed morphological and morphometric study was performed on the perialveolar bone surrounding the wounds. Three days after surgery (inflammatory phase) the bone wounds were occupied by hemorragic and inflammatory cells in both the untreated and IP-treated bone defects. Twenty-eight days after surgery, bone formation was evident with new bone spiculae particularly concentrated in the area of the bone lesion closest to the adjacent periodontal ligament. Morphometric measurements of the areas occupied by new bone showed that the synthesis of perialveolar bone was significantly stimulated by IP. The repair of the bone defects by new bone formation progressed by day 40, but only in the presence of IP were the original holes almost completely repaired. Conversely, biostite and Htr did not influence promotion of new bone formation. In conclusion, the results of the present study are consistent with a role of IP in stimulating osteogenesis and suggest that this compound could represent a potential therapeutic tool to promote repair of injured perialveolar bone.

[Acute rheumatic fever: a report]

Acute rheumatic fever (ARF) is still an important disease of the pediatric and adult age. The increased number of cases described in the literature in the last 10 years brought us to evaluate the ARF cases diagnosed in a Pediatric Teaching Hospital in the period 1988-1997. Most of the children with ARF presented with joint involvement even if patients with cardiac disease or chorea minor were numerous. About 50% of our patients with ARF did not refer a history of a febrile tonsillopharyngitis in the 15-60 days before the presentation of ARF. The remaining patients have had a preceding pharyngitis not adequately treated. In none of the subjects a throat swab positive for group A beta hemolytic streptococci was available. These results confirm the importance of the correct diagnosis and treatment of streptococcal pharyngitis but suggest that ARF can develop without any outstanding clinical evidence of streptococcal infection.

Rigid internal fixation of the jaws in an adult patient with facio-scapulo-humeral muscular dystrophy: report of a case

This study shows the advantages of rigid internal fixation in the surgical management of a facial deformity in a 29-year-old patient with facio-scapulo-humeral dystrophy (FSHD). After presurgical orthodontic treatment, surgery consisted of a Le Fort I maxillary osteotomy, with 5 mm of anterior movement, and fixation with miniplates. After mandibular sagittal split set-back osteotomy, internal fixation was applied on each side using two bicortical screws; no postoperative intermaxillary fixation was utilized. At the 2-year follow-up, the patient was satisfied with the surgical results; lip competence and occlusion were good. The advantages of using internal rigid fixation are: immediate osseous stability which does not require intermaxillary fixation, improved perioperative airway management (no preoperative tracheostomy) and earlier functional recovery.

A morphologic study of nodular lung carcinomas and their possible pathogenesis from a cluster of non-obstructive bronchiectasis

A very simple procedure has enabled us to show that nodular lung carcinomas correspond, to a high degree, to neoplasias arising in a cluster of bronchiectasis of the non-obstructive type. This pathogenesis explains their peculiar features: the round shape with a sharp borderline on the surrounding lung, the frequent cavitation, the prevailing histologic type of epidermoid carcinomas. At present, when thin-section CT allows discovery of bronchiectasis with no need for bronchography, this interpretation suggests the possibility of carrying out a prevention program which should consist of identifying the high-risk group of patients with bronchiectasis, 'sputum producers' and smokers, in which an early diagnosis of nodular lung carcinoma might be realized by periodical diagnostic cytology.

Radicular cysts are involved in the recruitment of osteoclast precursors

In consideration of the close relationship between radicular cysts and alveolar bone, it is important to evaluate the potential involvement of the neighbouring bone tissue in such lesions. In the present study, using cytochemical, immunocytochemical and morphological analyses, presumptive osteoclast precursors were revealed in the connective tissue of radicular cyst capsules. The osteoclastic nature of these cells was postulated by their positive staining for the enzyme tartrate-resistant acid phosphatase (TRAP) and by the expression of vitronectin receptor (VnR) on their cell surface. However, these cells did not express the vacuolar-type proton pump, suggesting that they may represent early osteoclast precursors infiltrating the cyst capsule. Cysts also contained activated small blood vessels whose endothelial cells expressed the VnR. This integrin receptor is important in the adhesion of preosteoclasts to the endothelial lining, a necessary step for their emigration out of the vasculature. Therefore, the intracystic vessels could represent a substrate for preosteoclast recruitment. These precursor cells may then reach the perialveolar bone surface and contribute to bone demolition together with those recruited by the resorbing surfaces. The bone-destroying potential of radicular cysts was confirmed by the presence of numerous osteoclasts with large resorption areas on the perialveolar bone surfaces exposed to the cyst capsules. The resorbed surfaces were usually located around the vascular canals of the Haversian systems.

[Perforations in Crohn's ileitis and their consequences in the natural history of the disease]

Not all Crohn's ileitis perforations occur in the peritoneal cavity; a proportion of them, which may be theoretically calculated as about 8%, occurs between the two leaves of the mesentery. These mesenteric perforations (which perhaps may be called more properly "penetrations") produce their pathological consequences in three consecutive anatomical compartments: 1) between the two leaves of the mesentery, causing mesenteric abscesses which are very dangerous, especially because of their embolisation into portal vessels (pylephlebitis, hepatic abscesses); 2) in the lower right quadrant of the retroperitoneum, causing what we call "Mesenteric Insertion Retroperitoneal Syndrome" (MIRS), consisting of a collection producing genito-femoral neuralgia, psoitis, obstructive uropathy and iliofemoral thrombophlebitis; 3) out from the pelvis, causing collections which in their spreading recall the cold abscesses of Pott's disease and which, diffusing along muscles and nerves, reach Scarpa's triangle, or the buttock and popliteal space.

[Perforation in Crohn's ileitis and its consequences in the natural history of disease. 2. Consequences of perforation in the peritoneal cavity: diffuse septic peritonitis, abscesses, external and internal fistulas]

Perforation of Crohn's ileitis occurring in the peritoneal cavity is always free perforation, but it causes usually a localized peritonitis, i.e. an abscess, and only in rare cases a diffuse septic peritonitis for the reasons expounded in the Part 1. Diffuse septic peritonitis has the common features of all perforative peritonitis; its surgical treatment must be ileocolic resection, simple suture of perforation being a serious mistake. Abscesses develop: as regards the ileum, about 30-45 cm from the ileo-caecal valve; as regards the abdominal cavity, in the right iliac fossa or in the pelvis, at a site where the ileum, weighed down by its chronic inflammation, rests. These abscesses have a wall like that of all abscesses, with no specific crohnian features. On operation, if technical considerations so require, part of the abscess wall may be left in place with no fear of recurrences or fistulas. Nowadays, most abscesses of the right iliac fossa are opened surgically; an enterocutaneous fistula follows. Most abscesses of the pelvis still open spontaneously into a hollow organ (sigma-rectum, urinary bladder), and rarely into the vagina or onto the perineum after penetrating through the levator any muscle and causing suppuration of the ischiorectal fossa.

[Perforation in Crohn's ileitis and its impact on the natural history of the disease. Note 1. Pathogenic process of the event, its relationship with intestinal obstruction, and its immediate consequences]

The pathogenesis and consequences of perforation in Crohn's disease were studied in 175 patients submitted to surgery. Perforation occurred in 40 (23%) patients with ileitis or ileocolitis, always in the terminal ileum; so-called "free" perforation occurred in 1 patient, "limited" perforation in all the others. Perforation is always a consequence of a chronic intestinal obstruction caused by the stricture of the terminal ileum, which becomes absolute because of the blocking by solid intestinal content. It occurs in the borderline between the stricture and proximal dilated loop, where the fissures (typical of Crohn's ileitis) are stretched to the utmost and dilated by the hyperpressure and distension of the wall following ileal stenosis. Perforation in the peritoneal cavity is always free; its consequence is usually not a diffuse septic peritonitis but an abscess, because only a small amount of intestinal content leaks out. This happens because in the proximal occluded bowel, pressure decreases abruptly following the spilling of intestinal content, particularly of gas. The abscess fed by intestinal content enlarges and finally opens into a hollow organ or onto the skin, causing a fistula (internal or external). The rational therapeutic approach to perforation and its consequences (the infrequent diffuse septic peritonitis, or the more common abscesses and fistulas) is always and only ileal stenosis removal.

Osteolytic processes in human radicular cysts: morphological and biochemical results

In an attempt to verify the nature of bone resorption processes on the bone surrounding radicular cysts, fragments of cysts with the adjacent bone tissue were studied by morphological, cytochemical and ultrastructural methods. Cyst fluid was analysed for its content of cytokines with osteolytic activity. The cyst wall exhibited several connective tissue extensions which penetrated the adjacent bone. Numerous multinucleated tartrate-resistant acid phosphatase (TRAP)-positive cells were seen at the tip of the intraosseous extensions of the cyst capsule and in direct contact with the bone tissue. Typical resorption lacunae were identified on the bone surface by scanning electron microscopy. Moreover, mononuclear TRAP-positive cells were seen within the cyst capsule. High levels of prostaglandin E2 (PGE2) and interleukin-6 (IL-6) were detected in the cyst fluids. In conclusion, active bone resorption may contribute significantly to the growth of these lesions within the jaws.

Intra-arterial hepatic chemotherapy with 5-fluorouracil and 5-methyltetrahydrofolate in the treatment of unresectable liver metastases from colorectal cancer

Treatment of patients with hepatic metastases from colorectal cancer using hepatic artery fluorodeoxyuridine (FUDR) has been reported to induce high remission rates but also a high incidence of limiting hepatobiliary toxicity. In an attempt to obviate the limiting FUDR toxic effects, a phase I-II study was undertaken to establish the efficacy and tolerability of intra-hepatic 5-fluorouracil (5-FU) when given in combination with 5-methyltetrahydrofolate. Patients with colorectal liver metastases (n = 17) received escalating doses of 5-FU as a 1 h infusion with a fixed dose (100 mg/m2) of intra-hepatic 5-methyltetrahydrofolate (4 h infusion) once a week. Dose limiting toxicity was hepatic and gastrointestinal (diarrhea) and occurred at doses > or = 350 mg/m2 5-FU. Other adverse effects included nausea/vomiting and cutaneous toxicity. One patient achieved a complete response and 2 a partial response (mean duration = 9 months) while 11 had stable disease. Patients with complete or partial responses had a mean survival of 17 months, while patients with stable disease survived 13 months and those with disease progression 5.5 months on average. These results suggest that this is a well tolerated regimen although with efficacy at the lower level of the range observed with fluoropyrimidines.

Efficacy and tolerability of brodimoprim in pediatric infections

Brodimoprim is a long acting broad spectrum antibacterial agent. It is a new selective inhibitor of bacterial dihydrofolate reductase, structurally related to trimethoprim. The aim of the present study was to investigate the efficacy and tolerability of brodimoprim (10 mg/kg on the first day, 5 mg/kg/die onward) in the treatment of upper respiratory tract infections in children (age range: 2-14 years). This open group comparative study was performed either in 68 children affected by bacterial pharyngotonsillitis (37 treated with brodimoprim, 31 with erythromycin 560 mg/kg/8 hours) or in 50 patients affected by otitis media (25 treated with brodimoprim, 25 with amoxicillin/clavulanic acid 50 mg/kg/12 hours) or in 52 patients affected by acute sinusitis (25 treated with brodimoprim, 27 with amoxicillin/clavulanic acid 50 mg/kg/12 hours). All patients were clinically evaluated before admission, during the trial and 48 hours after the last dose of antibiotic. At the same time blood and secretion samples were collected for hematology/biochemistry and microbiological assays. A total of 170 subjects were treated and 141 patients demonstrated a clinical recovery/improvement following the treatment period, with approximately the same recovery rate (83%) among the groups. The bacteriological response was evaluated in 169 subjects. Eradication of pathogens was documented in 27 subjects treated with brodimoprim and 28 with erythromycin in the pharyngotonsillitis group, in 22 subjects treated with brodimoprim and 16 with amoxicillin/clavulanic acid in the otitis group and in 17 subjects treated with brodimoprim and 20 with amoxicillin/clavulanic acid in the sinusitis group. The overall eradication in brodimoprim treated patients was 77% in comparison with 76% of eradication obtained in the control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

A double-blind comparison of nimesulide and ketoprofen in dental surgery

The efficacy and tolerability of nimesulide were compared with those of ketoprofen when administered rectally in a double-blind investigation of 46 patients scheduled for dental surgery. Nimesulide was more effective and more rapid than ketoprofen in ameliorating the painful inflammatory symptoms (pain at rest and upon mastication) and signs (swelling and hyperaemia) associated with the operation. These effects were accompanied by improved quality of sleep and recovery of masticatory and swallowing function, which was superior for nimesulide-treated patients.

[Extensive lymphadenectomy in the therapy of cancer of the left colon and rectum: an analysis of the anatomicopathological data]

In the last 12 years in our surgical service, radical resection was performed in 142 patients with cancer of left colon and in 145 patients with rectal cancer. Extended lymphadenectomy was always realized: preaortocaval lymphadenectomy in colonic cancer; preartocaval and pelvic lymphadenectomy in rectal cancer. The incidence of C stage was 40.14% in cancer of left colon and 40.68% in rectal cancer. Neoplastic diffusion in preaortocaval lymph nodes was only in a patient with colonic cancer, never in patients with rectal cancer. The incidence of neoplastic diffusion in pelvic nodes was 3.12% (0 in superior rectum; 6.25% in medium rectum; 2.4% in inferior rectum). In 1 of 90 patients with tumour of medium or inferior rectum, we relieved tumoural involvement of pelvic nodes without neoplastic diffusion in regional nodes. These anatomo-pathological data subline: a) the low incidence of neoplastic diffusion in preaortocaval nodes in cancer of left colon and rectum; b) the importance of pelvic lymphadenectomy in cancer of medium and inferior rectum.

Gastric cell proliferation kinetics and bile reflux after partial gastrectomy

Thirty-four randomized, partially gastrectomized subjects (12 with a Billroth II, 11 with a Billroth I, and 11 with a total biliary diversion reconstruction) were studied in order to assess the relationships between bile reflux, gastric histology, and cell proliferation kinetics. Bile acid quantity and concentration in the gastric aspirates progressively decreased from Billroth II to Billroth I to total biliary diversion (after which reflux was almost absent). Perianastomotic mucosa in Billroth II subjects showed the greatest degree of foveolar hyperplasia, and this decreased markedly with increasing distance from the anastomosis. Hyperplastic changes were less evident in Billroth I, and virtually absent in total biliary diversion subjects. The overall foveolar hyperplasia-like behavior of cell kinetic parameters (total pit cell number, labeled pit cell number, and labeling index) was shown. Moreover, subjects with mean bile acid concentration greater than 150 mumol/L had both a greater prevalence of foveolar hyperplasia and greater values of cell kinetic parameters than those with mean bile acid concentration less than or equal to 150 mumol/L. A superficialization of the proliferative compartment was also evident in the former group. These results show a close relationship between postgastrectomy bile reflux, foveolar hyperplasia, and cell kinetic parameters. Histologic and cell kinetic findings are probably the expression of gastric adaptation to chronic bile reflux exposure. Moreover, the type and entity of cell kinetic involvement and its relationship to foveolar hyperplasia and reflux may suggest new "tools" in post-gastrectomy surveillance and help to clarify patterns of gastric carcinogenesis.

[Ectopic salivary tissue in the mandibular region]

The presence of salivary tissue into the mandible represents often the submaxillary gland dislocation into the maxillary bones. Together with a literature revision, we have analysed the histogenetic hypothesis of this eterotopia and its prognostic implication. At last it has been described a clinical case treated in our Institute.

[Intrathoracic revascularization of the stomach in gastroplastic reconstruction of the esophagus]

Reconstruction of the thoracic esophagus after esophagectomy is usually achieved using the stomach which, after gastrolysis through an abdominal approach, is pulled into the right thoracic cavity and anastomosed to the esophagus. After gastrolysis by conventional methods, the blood supply of the stomach exclusively depends on the right gastric and epiploic arteries. In some cases, these arteries cannot ensure sufficient blood supply to the fundus of the stomach, which is at higher risks from a vascular point of view, since it depends on the intraparietal capillary anastomoses between the gastric branches on the left inferior gastric artery, the intraparietal rami of the short gastric arteries, which have been cut, and the parietal rami of the anterior cardiotuberous artery. When macroscopic signs of ischemic disorders of this area are observed intraoperatively, resection of the fundus of the stomach would considerably reduce the length of the organ that could be used for gastric esophagoplasty. To avoid this, we have been implementing an intrathoracic revascularization technique consisting in anastomosing the left gastric artery, either directly with the right internal mammary artery, or through a shunt with the saphenous vein between the subclavian artery and the left gastric artery itself. Finally, the intensification of the venous circle is performed by anastomosing the left gastric vein and the azygos vein. Details of the surgical technique, as well as the results obtained, are illustrated.

[Ultrastructural relief of unaffected mucosa in recurrent oral ulcer patients. 2]

Electron microscopy was performed on clinically normal vestibular mucosa biopsies of two patients affected with recurrent oral ulcers. Apoptotic cells were absent from vestibular mucosa; this is in contrast with the pathogenetic theory proposed by Honma et al., 1985 (1). Only a few modifications in the keratinization process (intracytoplasmic desmosomes, electrondense granules in basal keratinocytes) and an unusually high number of dendritic cells were found; dendritic cells could be involved in local immunological iperreactivity, responsible for the ulcers of these subjects.

[Surgical treatment of oroantral fistula. Experience with the use of fibrin glue]

Personal surgical experience in the treatment of oro-antral fistulas is reported. Fifteen patients underwent plastic surgery (palatal strip) and fibrin glue was used to guarantee a better take of the strip.

[Bilateral chronic luxation of the mandible. Clinical case]

The pathogenesis and treatment of the long standing dislocation of the mandible is showed by the Authors. A case of four months duration in a young man is presented. The reduction was accomplished manually under intravenous anaesthesia and relaxant drug. By the means of a digital electromyography a survey of the masticatory muscle before and after reduction was done. The normalisation of masticatory function was closed followed by improvement of electromyographic results.

[Red lesions of the oral mucosa as early manifestations of squamous cell carcinoma]

Red lesions of oral mucous membranes may have various aetiology, but we must never forget, that among them, there is also the so-called erythroplachia, the oral variation of the better known and mainly genital form of Queyrat, which is one of the most typical examples of cancer in situ (c.i.s.).